DD No. APPLICATION FORM ADMISSION TO POST GRADUATE DEGREE COURSE IN SIDDHA [M.D(SIDDHA)] AT GOVERNMENT SIDDHA MEDICAL COLLEGE, PALAYAMKOTTAI AND

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1 DD No. Name of Bank & Branch Date Amount APPLICATION FORM ADMISSION TO POST GRADUATE DEGREE COURSE IN SIDDHA [M.D(SIDDHA)] AT GOVERNMENT SIDDHA MEDICAL COLLEGE, PALAYAMKOTTAI AND GOVERNMENT SIDDHA MEDICAL COLLEGE, CHENNAI 106 (NOTE : ALL PAGES SHOULD BEAR CANDIDATE S FULL SIGNATURE) Application No. : Space for photograph (To be attested by self) 1. Name of the candidate in capital: (as in certificate) 2. Father s Name : 3. Date of Birth : 4. Sex ( please tick ) : M F 5. Nationality : 6. Nativity: Evidence to be produced : (Not required if the candidate has Studied from 8 th std. to BSMS course in Tamil Nadu) Signature of the candidate (Both service and Non service Applicant)

2 7. Community ( please tick) : OC BC BCM MBC/DC SC SCA ST 8.Name of the Caste and Sl.No : 9. Mother Tongue : 10. Languages Known : (a). Mailing Address (Residential): (b). Office Address, if any Mobile Nos: ID: 12.(a). Qualification : (b). College from which passed and Affiliating University. : (c) Is this Degree recognized by the Central Council of Indian Medicine, New Delhi (d) Month and Year of Passing the Final : Year (Class if any in which passed) (e). Date of completion of the Internship: (Enclose proof) 13. Medical Registration No. Allotted by CCIM/TNSMC

3 (Details to be furnished in application or to produce before counseling) 14. Nature of employment held : subsequent to passing of BSMS/BIM equivalent course with duration. 15. Whether Service candidate or Non Service candidate ( Refer Para IV of the Prospectus) 16. Are you applying under any special Category mentioned in (para V,65. If yes, specify the category) Signature of the candidate. (Both Service & Non Service Applicants)

4 FOR SERVICE CANDIDATE ONLY 17. Date of first appointment in : Tamil Nadu Medical Service 18. Service Status ( please tick ) : Temporary / Probationer /Approved Probationer 19. Whether selected by Tamil Nadu Public Service Commission and if yes year of publication of results : 20. Date of Joining in Service as TNPSC Candidate : 21. Date of Regularization. : 22. Date of Completion of Probation. : 23. Total Service as on : Year Month Days 24. Whether any disciplinary proceedings : are pending against the candidate if so, present stage. 25. Details of contractual obligation to the : Government if any. Signature of the candidate. Place: (only service applicants) Date:

5 DECLARATION BY THE CANDIDATE I I S/o,D/o,/w/o, do hereby solemnly and sincerely affirm that the statements made and information furnished in my Application Form as also in all the enclosures thereto submitted by me are true to the best of my knowledge and belief. Should it however be found that any information furnished therein is untrue. I realize that I will be liable for criminal prosecution and agree to forego without demand, my seat in the College at any stage. Station: Date : Signature of the candidate. II I have not undergone the Post Graduate Degree in Siddha Medicine in anyone of the disciplines and discontinued the course on my own accord (or) on any other grounds after 6 months from the date of joining the course. Station: Date : Signature of the candidate.

6 CERTIFICATE Certificate to be produced by candidate who apply one seat allotted for the son or daughter of a Central Government Employee working in Tamil Nadu and who is not a native of Tamil Nadu. Certified that Thiru./Tmt. Parents of Thiru/Tmt./Selvi a candidate who has applied for admission to M.D (Siddha) course is working as the office of the in of the Central Government and certified that he/she is not a native of Tamil Nadu. Place: Signature of Head of office with Designation. Date: Office seal:

7 ANNEXURE I CERTIFICATE OF Nativity in Tamilnadu Certified that Dr. S/o. D/o. W/o. Thiru.. an applicant for admission to Post Graduate studies is residing at in Tamilnadu is a Native of Tamilnadu. Taluk District. Signature of the Village Administrative Officer. State.. Office Seal: Signature: Name and Designation: Station: Dare: The certificate should be obtained from an Officer of the Revenue Department not Lower in rank than that of a Deputy Tahsildar I.A.S. officer of this State can issue this certificate based on personal knowledge for not less than three years

8 INSTRUCTIONS FOR NATIVITY CERTIFICATE : 1. This Certificate should be issued by an officer of the Revenue Department not below the rank of Tahsildar in the Taluk concerned. 2. This Certificate should not be issued by the Special Tahsildars, Deputy Tahsildars such as Loans, Land Acquisition, Election, Excise and HQs, Deputy Tahsildars, Special Deputy Collectors, Assistant Commissioner of Agricultural Income, Excise, Elections etc. 3. This Certificate should be signed also by the Village Administrative Officer. 4. The Certificate should bear the stamp of the office of the Officer signing the Certificate. 5. Any foreign national irrespective of the period of study in the State will not become eligible to apply for this course. No certificate of Nativity in the State of Tamil Nadu, should therefore be issued to Nationals of other countries for this purpose. 6. The certifying officers should insist upon clear proof of the Nativity of the Parent or Guardian of the candidate and satisfy themselves on the genuineness of the residential qualification. 7. Residence Certificate will not be considered as Nativity Certificate. 8. The guidelines prescribed for the issue of Nativity Certificate and they are as follows as per Letter No.RA.V(B)16932/2000, dated of the Special Commissioner andcommissioner of Revenue Administration, Chepauk, Chennai-5. (i) The parents/guardians of the applicants/students or the applicants themselves should have permanently resided continuously for a period of five years in Tamil Nadu. (ii) Permanently residing for a period of five years should be supported by Documentary evidence. ( iii) The family ration card, Electoral Roll, Census List if taken recently, documents like sale deed, tax receipt etc. relating to the property owned by

9 either of the parents or by the applicant may be verified. (iv) The Transfer Certificate issued by the School authorities where the applicant had studied last may be verified to know whether he was in the state for five years. (v) Enquiry in the village / place of residence of the neighbour / Village Administrative Officers regarding continuous residing. (vi) To ensure that wrong or incorrect address had not been furnished to obtain The certificate. (vii) The birth place, the present place of residence of the parent / father, Permanent assets, mother tongue, place of education, place of marriage of the applicant / parents, the period of stay in and outside Tamil Nadu can also be considered before issuing certificate.

10 ANNEXURE II SERVICE PROFORMA The service particulars of Dr. S/o. D/o. W/o. Thiru. who is an applicant for admission to M.D., Siddha Course session are hereby furnished. 1. Designation of the Present Post. 2. Service Status (Tick Appropriate Box) Probationer Approved Panchayat GOI service Undertakings/Organisation Probationer Union service of GOI / GOTN. 3. Date of First Appointment as TNPSC Selected : 4. Duration of Service as on Details of posts held and place of service POST HELD Nature of Service PLACE DURATION FROM TO ( If space is not sufficient, separate sheet indicating the above particulars should be enclosed with the signature and office seal of the competent forwarding authority)

11 6. If the candidate is under any subsisting Contractual obligation to the Govt. for any reason / details PLEASE PROVIDE THE SAME.. 7. Are there any Criminal Proceedings, Inquiry or Disciplinary Proceedings pending or Contemplated against the candidate. If so, application should not be forwarded. 8. Whether the candidate has produced an undertaking as mentioned in prospectus para Whether the Candidate has worked in a hilly area? If so, the details about duration of service and with the place of posting etc. may be furnished. The leave if any, without Casual Leave, shall be Excluded Station: Signature: Date: Office Seal: Note: All applicants should obtain service certificate from the competent authority Applications without Service Particulars duly authenticated by the competent authority are liable for rejection. Candidates above 50 years as on are not eligible to apply.

12 ANNEXURE III MEDICAL CERTIFICATE FOR PHYSICALLY DISABLED (Minimum disability of the locomotor disorders of lower limbs between 40% to 70% ) The District Medical Board District..certify that we have this day of 2015 examined the candidate whose particulars are given below. 1. Name of Candidate : 2. Father s Name : 3. Sex : 4. Approximate age : 5. Identification marks. : Orthopaedically Disabled : Nature of Physically Disabled. 7. (I) Extent of disability (mention the % of disability) (Upper limb function must be normal) : (II)Whether the candidate is fit to undergo Post Graduate Degree Course : YES / NO.

13 (The Medical Board should satisfy itself that all the criteria mentioned in the foot note are met with before giving the fitness) Signature of the Applicant Members Signature of Chairman of the Medical Board. PLACE: 1. Designation : DATE : 2. Office Stamp : NOTE : 1. Upper limbs should be normal. 2. The above certificate should be issued only by the District Medical Board of the area concerned constituted for the purpose after due physical examination by Board.

14 M.D. (SIDDHA) SESSION SCRUTINY FORM (To be filled by the candidate as per the entries made in the application form) Application No. No Details 1 Name in Capital Letter Dr. 2 Sex Male or Female 3 Mailing Address Contact Phone No. with STD code Office use only Mobile No. I.D Pin Code: 4 Date of Birth Date Month Year 5 Nativity TN Others Mother Tongue Tamil Others Community OC BC BCM MBC SC SCA ST Service Particulars Service Candidate Non-service Candidate Date of Completion of CRRI Training 10 Total Number of years as on after completing CRRI to a maximum of 10 years 11 Medical Registration No. and Date of Registration 12 Service Status:1.State Govt. 2.Central Govt 3.TN Govt. Undertaking/ Local Bodies in TN 4.Central Govt. Undertaking in TN 13 BSMS/BIM Final Year Mark 14 Years served in the Hill Area (Excluding leave other than C.L.) 15 Whether Discontinued PG Degree Previously, if yes, State Branch and Date of the Discontinuation. Date Month Year Years Months Days Branch and Date

15 I sincerely affirm and state that the information furnished above is true and correct to the best of my knowledge and belief. Station: Date: CANDIDATE S SIGNATURE. Office Use Only. Scrutinising Officer. Signature Date Remarks

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